May 22, 2012

the HAES files: Why Obesity is NOT an Eating Disorder

by healthateverysizeblog

by Jon Robison, PhD, MS

From time to time I overhear or read about people discussing whether obesity should be considered an Eating Disorder (ED). I have even seen obesity listed along with anorexia and bulimia as if it were just common knowledge that it belonged there. This is just wrong on so many levels that it almost seems like it is not worth acknowledging the discussion. On the other hand, it is so often promulgated both in the lay media and in scientific circles that perhaps it is important to elucidate the ways in which the classification of obesity as an ED makes no sense.

To begin with, Eating Disorder Reviews defines EDs as:

Extreme expressions of a range of weight and food issues…serious emotional problems that can have life threatening consequences.

Obesity, on the other hand, is defined as a Body Mass Index (BMI) equal to or greater than 30. It is a measure of height and weight (kg/m2). Just as there are different eating disorders, there are other measures of height and weight; The Ponderal Index, The Body Mass Prime and The Body Volume Index to name a few. An ED is a serious emotional problem/illness and obesity is a measure of height and weight. So, on the most basic level comparing obesity and eating disorders is somewhat like comparing apples and oranges.

Actually, the comparison is really a good deal more obtuse than that because apples and oranges are at least both fruits. The comparison between obesity and eating disorders is really more akin to comparing an apple with a chair. You can’t sit in an apple and you can’t eat a chair!

Actually, on a somewhat lighter note, I have seen a chair shaped like an apple, but you still can’t eat it.

It is important to remember (as I discussed in a previous blog post) that this BMI measure (1) was never meant to be a measure of health and (2) is a population statistic not meant to be used on individuals. So, making connections between this measure of obesity and the serious emotional health issue of EDs is scientifically unjustified and inappropriate.

On the next most basic level, it is certainly true that body weight and eating disorders both have something to do with food. Yet, the evidence that people labeled as obese eat more than other people is inconclusive at best, with some recent research even suggesting that just the opposite may be the case.  So, the very common suggestion that you can know whether someone is eating the “proper amount” of food (or the “right kind” of food for that matter) by looking at them is not supported by the evidence and therefore, doing so can best be defined as prejudice (pre-judging).

Of course, the lack of supportive evidence for this conclusion does not stop people from continually making it. In fact, the word obesity itself comes from the Latin obesus, whose primary definition, “one who has become plump through eating,” confirms the misconception.  Instructively but perhaps not surprisingly, the secondary definition for obesity usually includes the words coarse and vulgar.

From a phenotypical perspective, the concept of obesity as an ED also makes no sense. Most patients with anorexia nervosa and bulimia nervosa have always been thin and “normal weight” people.  However, everyone knows that the vast majority of people in these weight categories do not have an ED. With the acknowledgement of Binge Eating Disorder (BED), many therapists are now seeing fat people who have an eating disorder. As is true with people of any size, of course, the vast majority of fat people also do not have BED. Research suggests that somewhere between 4% and 8% of people labeled as obese may suffer from BED which means that the overwhelming majority, 92% to 96%, do not!

In conclusion, here is what we can now say about the relationship between obesity and ED. They are about as related as the chair and the apple. Suggesting that someone has an ED simply by virtue of their BMI is prejudicial, unscientific and unethical. As fat activist and author of Fat!So? Marilyn Wann puts so eloquently:

The only thing anyone can diagnose by looking at a fat person is their own level of prejudice toward fat people.

 

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May 15, 2012

the HAES files: Uncommon knowledge about changes in body weight–part 2

by healthateverysizeblog

by Lily O’Hara, BSc, Postgrad Dip Hlth Prom, MPH, PhD (c)

In Part 1 of this article I addressed some of the less well known contributors to increased body weight, including the strong role played by genetics, proteins and bacteria in the gut, and infections with bacteria and adenovirus. I also discussed factors such as inadequate sleep duration and quality, chronic work or life stress, and exposure to endocrine disrupting chemicals. Finally I discussed the studies that demonstrate the contribution of dieting and weight control behaviors to weight gain. In part 2 of this article, I examine a range of environmental factors and their contribution to increased body weight. The article draws on the PhD thesis I am currently completing, and is therefore written in an academic tone, and includes a number of references.

In recent years, antiobesity researchers, policy makers and health professionals have increasingly pointed to the contribution of environmental change to the obesity epidemic [1-8]. So called ‘obesogenic’ environmental factors are most commonly described as those environmental factors that contribute to changes in nutrition and physical activity – the ‘Big Two’ [9] – by making unhealthy behaviors the easy or default choice for people [6]. On the nutrition side, ‘obesogenic’ environmental factors are purported to include the heavy promotion of fast food, energy dense snacks and sweetened beverages, the ready availability of these foods in schools, the low cost and large serving sizes of these foods, the density of fast food outlets in poor neighborhoods, the high cost of fresh foods, the lack of time to prepare fresh meals and the reduction in family meal time. On the physical activity side, ‘obesogenic’ environmental factors are purported to include changes to the urban environment and perceptions of safety which have led to reduced use of active transport, increased car use, reduced outdoor play and increased indoor (sedentary) play and recreation, technological advancements which have resulted in reduced need for physical activity and increased opportunity for sedentary behaviors at home and at work, and reduced time dedicated to physical activity in schools.

The arguments for the ‘Big Two’ [9] ‘obesogenic’ environments have relied on a combination of ‘common sense’ about presumed mechanisms of action together with results from ecological studies that show associations between the specific ‘obesogenic’ environmental factors and aggregate population rates of ‘obesity’ prevalence or incidence. However critics point out that correlation is not the same as causation [10] and the ‘ecological fallacy’ refers to the inability of ecological studies to attribute any causal relationship between exposure to any putative ‘obesogenic’ factor and the development of disease in individuals [11]. As such these studies are considered to be useful for generating hypotheses about the causation of changes in body weight and health outcomes, but not for testing them [11].

Only a small number of scientific studies have investigated the relationship between ‘obesogenic’ factors and their purported ‘obesogenic’ behavioral correlates. A systematic review of 28 studies examined the relationship between physical, social, cultural and economic environmental factors, ‘obesogenic’ dietary behaviors and body weight in adults [3]. BMI was consistently associated with the food environment, whereas ‘obesogenic’ dietary behaviors were not. Living in a socio-economically deprived area was the only environmental factor consistently associated with ‘obesogenic’ dietary behaviors. There were no other consistent relationships between ‘obesogenic’ environments and ‘obesogenic’ dietary behaviors.

On the physical activity side, ‘obesity’ researchers and public health policy makers have focused a lot of attention on the physical environment and its relationship with active transport (walking or riding a bicycle as a means of transport rather than for recreation or leisure). The assumption, based on ‘common knowledge’ about the relationship between physical activity and body weight, is that people who use active transport are more physically active than those who don’t, and will therefore have lower body weight. This ‘common knowledge’ has been tested in numerous studies, and the findings are at best equivocal. A recently published systematic review of studies focused on adults concluded that there is “limited evidence” that active transport is associated with more physical activity or with body weight [12]. A systematic review of the evidence with respect to active school transport by children and adolescents showed that children who walked or rode their bikes to school tended to be more physically active overall than passive commuters, however only one study of the 10 that examined the effect showed any impact of active school transport on body weight. The authors concluded that “evidence for the impact of active school transport in promoting healthy body weight for children and youth is not compelling [13].

These studies on just a few select components of the Big Two ‘obesogenic’ environments show that the ‘common knowledge’ about the environmental influences on eating and physical activity, and therefore on body weight, may not be quite as straightforward or simple as portrayed. Although the research literature and public health policy continues to be dominated by the Big Two, some studies have examined other factors for their potential effect on body weight. The remainder of this article focuses on these factors.

A narrative review of ‘obesogenic’ environmental factors beyond the Big Two proposed 10 factors for which there is strong evidence of a causative role in increased average weight in the population [9]. In addition to sleep debt, exposure to endocrine disruptors, and in-utero effects of under and over-nutrition discussed in part 1 of this article, the review found strong evidence of a range of other environmental and social factors that contribute to increased body weight.

Reduction in variability in ambient temperature has resulted from increases in the temperature control of living, working and leisure environments. The ‘thermoneutral zone’ is the range of ambient air temperatures in which the body does not need to expend any energy to remain at a comfortable temperature. Ambient temperatures outside of this zone – too hot or too cold – require energy expenditure, and spending time in temperatures above the thermoneutral zone also reduces food intake. As countries become more industrialised, the proportion of homes with central air conditioning increases, and people spend more time in the thermoneutral zone. The energy expenditure required to maintain physical comfort has therefore been significantly reduced and the review authors propose that this reduction has contributed to increased body weight [9].

Another widespread social change, in western countries in particular, is decreased smoking rates. Nicotine has a thermogenic (heat generating) effect and is also well known as an appetite suppressant, both of which contribute to body weight regulation. Smoking rates have decreased steadily since their peak rates in the 1940s and the Centers for Disease Control and Prevention in the US estimate that the reduction in the prevalence of smoking has made a significant contribution to increases in average body weight [9].

Increases in the prescription rates of medications that lead to weight gain is proposed as a likely cause of population weight gain [9]. Medications known to contribute to weight gain include antipsychotics, antidepressants, mood stabilizers, anticonvulsants, antidiabetics, antihypertensives, steroid hormones, contraceptives, antihistamines, protease inhibitors and HIV antiretroviral drugs. Most of these drugs have either been introduced to the market in the same period that average body weight increased, or their use increased dramatically. The authors therefore regard the case for this putative cause as very strong.

Demographic changes have also been proposed as likely candidates for increased average body weight at the population level [9]. These include changes in the distribution of ethnicity and age, and increased average age of childbirth, all of which are associated with increased average body weight.

Finally the authors of the review point to biological factors related to mating that may have contributed to increased average population weight [9]. Firstly they present evidence that there is a reproductive selection bias for higher BMI, which means that fatter people are more likely to have more babies, and that this genotype is therefore more likely to be passed on to their offspring. Secondly, they propose that assortative mating means that there is a higher probability that phenotypically similar individuals will mate – in other words that fat people are more likely to mate with other fat people [9].

A recent study proposed that increases in acidic load from rising atmospheric carbon dioxide have contributed to increases in average weight for humans [14]. A large study published in 2011 examined changes in average mid-life body weight over the past few decades of over 20,000 animals from 24 populations living in close proximity to humans including primates and rodents in research colonies, domestic dogs and cats, and feral rodents [15]. Across all of the animal populations studied there were significant increases in average mid-life body weight, providing further evidence that the aetiology of increasing body weight is not yet well understood.

Despite the significant body of evidence on the contribution of genetics and a multitude of other factors to weight gain, antiobesity researchers and policy makers continue to posit the ‘common knowledge’ that eating too much and moving too little results in fatness, and that people have the capacity to consciously change these behaviours and thereby change their body weight. This two part article sheds light on some ‘uncommon knowledge’ about factors that contribute to body weight at the individual and population levels. Already it is clear that ‘common knowledge’ about body weight is about as accurate as the 16th Century ‘common knowledge’ that the sun revolves around earth. No doubt, with the enormous sums of money currently being invested in ‘obesity’ research, we will witness even more discoveries that shed new light on the incredible complexity of body weight regulation.

Please click here to access the numbered references.

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May 10, 2012

the HAES files: Top 10 Reasons to Be Concerned About “The Weight of the Nation” Documentary

by healthateverysizeblog

by Fall Ferguson, JD, MA

Over the last few days, I have been involved in preparing ASDAH’s “Debate the Weight” response to HBO’s documentary series, The Weight of the Nation (WOTN).  As I write this, I still haven’t seen the series yet; it’s scheduled to air on May 14 and 15.  Nevertheless, like many of you, I am already worried about it.  Here are my top 10 reasons why.  [Other than the last two, the order of the reasons should not be interpreted as a ranking of importance.  They’re all important to me.]

10.  The misguided focus on obesity.  The series identifies weight as “the problem” when the focus of our public health efforts should be health promotion and the prevention of chronic disease.

9.  The appeal to fear.  The publicity for the series (and I am guessing the actual documentary itself too) uses fear as a means of persuasion and motivation for change.  Few things are as destructive to health and well-being as fear.  I also question whether health professionals who use fear to influence people are behaving ethically.

8.  Disservice to thin people.  Thinner people may get the message that their lower weight means they don’t need to take care of their health or be concerned about preventing chronic diseases.

7.  Unhealthy behaviors.  The emphasis on obesity—indeed the tagline alone (“We have to lose to win”)—increases the pressure people are already feeling to engage in unhealthy behaviors such as restrictive dieting, weight cycling (“yo-yo dieting”), and other disordered eating patterns.

6.  Wrong message to children.  Some defenders of the documentary have pointed out that it includes a nuanced treatment of how we need to change the “environment” in order to change the incidence of obesity.  Changes in our infrastructure and health care system that promote health are all well and good, but I disagree with framing those changes as needed to “solve” obesity.  Moreover, I am afraid this point will be lost on many, especially kids, who tend to focus on the big picture.  I think the big picture that kids will take away from WOTN is: Obesity bad, thin good. With public health campaigns like this, no wonder weight bullying is more prevalent than any other form of bullying, and more kids than ever are being diagnosed with eating disorders.

5.  Increase of weight stigma.  Based on the trailer, I expect to see lots of people blaming themselves and expressing shame over their weight—creating the impression that it’s blameworthy and shameful to be fat.  And, spare me the “experts” engaging in hyperbole such as “Obesity will crush the United States into oblivion” (a quotation from the trailer).  Notice the not-so-hidden metaphor—clearly there is a fat person lurking behind every corner, ready to jump on you and crush you with her humongous fatness! (Boo!)

4.  No recognition that our obsession with obesity is contributing to the rise in eating disorders.  The producers appear to be completely oblivious to the notion that their fear-mongering and hyperbole might contribute to the marked increase we are experiencing in the incidence of eating disorders in all demographics.

3.  Misuse of our tax dollars.  This series is being co-produced by several government agencies.  I’m angry—and I think you should be too—that our tax dollars are being spent this way.  We all deserve better.

2.  Misinformation abounds.  I don’t have the time or space here to catalog every item of misinformation that I found on the website.  ASDAH has created a “Debate The Weight” response that provides some guidance on this, and watch for additional resources to be added after we’ve gotten a look at the documentary itself.  For now, I’ll just start with the fact that the information in the “weight loss” tab makes it sound like anyone can lose weight and keep it off permanently.  Not!

1½. What’s not being said.  (OK, I couldn’t limit my list to 10, but who ever heard of a “top 11” list?)  One of my biggest concerns is what I suspect won’t be said anywhere in the documentary.  ASDAH offered to consult with the producers to offer a Health At Every Size® point of view, but never heard back.  Based on their website and the trailer, I don’t see any acknowledgement of alternative points of view.

And, where is the recognition that we have serious problems with body shame and eating disorders in U.S.?  The things that worry me about “the weight of the nation”—for example, I worry about how much people hate their own bodies and how much they fear the bodies of fat people—well, I’m guessing these things don’t even make the grade in the HBO series.

And the number one reason I am concerned about WOTN…

1.  Escalation of the cultural war on obesity.  WOTN is getting everyone even more worked up than they were before about the so-called “obesity crisis.”  This shouldn’t be a surprise; I believe that is the producers’ intention.  With a few welcome exceptions, no one seems willing to bring a critical lens to bear on these issues.  As a fat person, I am tired of being engaged in a war that I didn’t start and that uses my body as cannon fodder.  As a health educator, l deplore the damage done to people’s health and self-esteem by our cultural war on obesity and I deplore the misinformation about health that masquerades as “public health messaging.”

I know there are some great resources out there for coping with the media storm to come.  Deb Burgard’s blog piece on Stereotype Management Skills for HBO Viewers provides a brilliant and most welcome “’viewers’ guide’ to conserving sanity points.”  And I was part of creating ASDAH’s “Debate The Weight” response to the documentary (debatetheweight.com), so I know there’s some useful tools there.  Still and all, these are tough times, right?

A colleague who works in PR recently reminded me that controversy is almost always good publicity for everyone involved.  I’m not so sure about that right now.  What I am sure of is how grateful I am for the HAESSM community, and for the sense that we are in this “peace movement” together for the long haul.

What are your reasons for being concerned about WOTN?

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May 8, 2012

the HAES files: Stereotype Management Skills for HBO Viewers

by healthateverysizeblog

by Deb Burgard, PhD

I don’t know what HBO’s series, The Weight of the Nation*, is going to say, but if the previews are representative, you might want to use this handy “viewers’ guide” to conserving sanity points.

Critical Thinking Skills 101

The main flaw in the traditional view is to think that if an event happens in the life of fat people, it is because they are fat.  All of us are trained to think this way, but there are some questions to ask that can help reverse the brainwashing:

“Does this happen to thin people too?”

  • I eat too much.
  • My doctor tells me I have diabetes.
  • That person I was attracted to rejected me.
  • I can’t get down on the floor and play with my grandchildren.

Fat is blamed for almost anything negative that happens in life.  But thin people don’t have their fatness to blame, so when those same things happen to them, they have a whole universe of possible solutions.  Those same solutions should be available to fat people – why would we think the only solution is to turn them into thin people?

There is a version of blaming fat where the very presence of fat people in society is enough to blame them for the society’s problem.  The question to ask here is,

“If everyone was thin, would we still have this social problem?”

  • There are problems with the way we produce food, and inequities in how we distribute food.
  • We are living in an environmentally unsustainable way.
  • We don’t have a functional healthcare system.
  • The baby boomers are a big demographic group who are living longer and will cost more in their final phase of life.
  • Our schools are struggling to feed, educate, and exercise our children with too few resources.
  • The demands of making a living leave little time for caring for ourselves and each other.

Blaming fatness keeps us from addressing the root causes of our problems, and is clearly unfair to fat people.  Many powerful people understand this, but find it expedient to frame a problem in terms of fat in order to bring attention to it.  They don’t think people will just attend to the real issue unless they whip up the fat panic.  Whether it is being pessimistic that people will exercise if it is not in the context of a weight-loss effort, or being pessimistic that people will care about our food environment if it is not in the context of a moral panic about fatness, the justification for whipping up the fat hatred is the same.  I say, have the courage to make your argument about the real issues and stop doing it on the backs of fat people.

Arm Yourself with the Facts

Here are some other key facts to keep in mind while you are watching:

  • The “epidemic” refers to a rise of 10-15 pounds in the average weight of US adults between 1980 and 1999.  The rise was over before most of the “obesity epidemic” rhetoric began.
  • The pictures illustrating “two-thirds of US adults are overweight or obese” are almost universally of people who represent less than 1% of the population.  People at a BMI over 50 are so rare that the CDC cannot estimate their actual prevalence in the population.  The photo that would actually represent the headline would be of someone the size of Will Smith or Tom Cruise.
  • We can re-cast public health authorities’ notion that we are “in denial” about our fat as their complaint that we are not buying into the BMI categories, which is actually a triumph of common sense, since BMI is such a lousy proxy for health, appearance, and even degree of actual fatness.  There is a fog of confusion around BMI—supposedly educated people seem to think that squaring, dividing, and converting to metric units adds more information than the height and weight data you started with.
  • The range of weights considered problematic in children was tripled in 2007 for no scientific reason, from the 95th percentile and up, to the 85th percentile and up.  This allows for dramatic statements like, “1 in 3 children in Georgia are overweight or obese,” even though pediatricians agree that even the 95th percentile and higher does not necessarily signify ill health.
  • Despite the alarm, Type II diabetes in children is so rare that the CDC has not been able to accurately estimate prevalence.  We need to focus on the lack of access to good medical care for many of these children and their families, rather than using them as poster children for public hate campaigns.

Challenging the Untested Assumption

The entire health argument for weight loss is based on a single untested assumption:

A weight-suppressed fat person has
the medical risk profile of a thin person.

Think about it.  There are no data for this, because there are so few weight-suppressed fat people who maintain weight suppression long enough to find out.  Instead, we have the illusion from medical data 6 months or a year into weight loss (which reverses with weight regain) that temporarily shows improved risk factors, like lower cholesterol or better fasting glucose levels.  If research was required to be at least 2-5 years in length, we would lose our illusion that weight loss is a solution, because neither weight loss nor health benefits last.

Fortunately, we have a more reliable way to obtain those improved medical outcomes for people who lose no weight but increase their movement levels or nutritional quality, and the physiological improvements last with the ongoing practices.

And if fat tissue loss was the key solution, why do we see no medical improvements with liposuction?

Follow the Money

When you are evaluating the claims made in the series, remember to follow the money.  Historically, every time the public appears to be getting hip to the fact that “diets don’t work,” there are massive responses from the weight cycling industry.  Their target this year is clearly communities of color and men, and their campaigns seek to shame people who are “in denial” about their weight.  One can picture the marketing execs around the table: “We got white women to hate their bodies – but we saturated that market long ago!”

Big pharma is constantly trying to create new markets, so making people who are not sick need treatment for “pre-diabetes” and “pre-hypertension” is a great money-maker.  The health insurance industry has always gotten away with discriminating against fat people and will politically get away with flouting the new healthcare law – should it survive – by charging higher premiums for the two-thirds of the country who are “overweight.”  My own profession of psychology is seeking to enshrine the current ineffective weight change interventions to make ourselves the “weight loss experts” who get the Medicare reimbursements.

All of these interests stand to lose billions of dollars if they tell the truth.  So remember, people are getting paid to hate you.

Stereotype/Stigma Management Skills

A worksheet for cultivating Stereotype Management Skills. (Please click on link at right for entire document.)

Critical thinking skills are all well and good, but there is another difficult aspect of public hate campaigns, which is of course, these are real people being obnoxious and mean to us.  We can be armed with all the facts in the world but the social reality is that it really sucks being the target of hate and bullying.  This handout provides a worksheet for cultivating Stereotype Management Skills.

When people are mean, we have to be especially careful not to blame our bodies. There is nothing about us or our bodies that deserves scorn or derision.  Take special care to honor your body and its wondrous capacities and gifts.  The problem lies outside of you and your body, with the bullies and the forces that benefit from fat hatred.

One of the most important things we can do when we are experiencing discrimination is to seek out our tribe.  This is the time to talk about what you are experiencing—in person, or on the listservs.  Also, ASDAH is preparing materials designed to help viewers understand and critique the rhetoric of WOTN documentary—to be posted soon. [Update: ASDAH's response has now been posted: www.debatetheweight.com]

Time for a Party!

It looks like WOTN plans to hit all the major “obesity” memes, like, “this generation of children’s lifespans will be shorter than their parents,” “obesity will bankrupt our healthcare system,” and “by 2050 our entire country will be obese.”  We could not have a better opportunity to plan big parties and play Fat Hate Bingo!  HBO says we have to lose to win, but we say, all you have to lose is your hate.

* The Weight of the Nation (WOTN) is scheduled to air on HBO on May 14 & 15, 2012.

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May 1, 2012

the HAES files: Uncommon knowledge about changes in body weight–part 1

by healthateverysizeblog

by Lily O’Hara, BSc, Postgrad Dip Hlth Prom, MPH, PhD (c)

The ‘common knowledge’ about body weight is that an increase or decrease in body weight is caused by a simple imbalance between the choices an individual makes regarding energy intake and energy expenditure, and that body weight is therefore ultimately within the conscious control of the individual. Although this mechanistic ‘common knowledge’ about body weight is extremely widespread, it is completely inadequate to explain changes in body weight over recent decades.

There is a growing body of evidence that demonstrates that physiological characteristics such as body weight are not simple at all, but result from complex interactions between genes, other biological factors, behaviours, life course experiences and exposures to biophysical and socioeconomic environments [1-4]. In this two part article, I discuss the contribution of a range of factors to increased body weight, beyond the ‘common knowledge’ of conscious choices about eating and physical activity. I do not explore the contribution to increased body weight of medical conditions such as hypothyroidism, Cushing’s syndrome, etc.

This article draws on the PhD thesis I am currently completing, and is therefore written in an academic tone, and includes a large number of references. (In fact I’ve been writing in this tone for so long now, I don’t really know how to write any other way.)

Before exploring the factors that may contribute to increased body weight at the individual and population levels, it is worth revisiting the evidence about trends in body weight over the past 40 years. Average body weight in many industrialized countries increased from about the 1970s onwards, though not equally across the weight spectrum. In contrast to the commonly held belief that ‘obesity’ rates are continuing to increase, high quality studies have shown that ‘obesity’ rates for children, adolescents and adults in fact stabilized in many countries around the turn of the 21st Century, and in some countries, such as England, ‘obesity’ rates for adolescents have actually decreased over the past decade [5]. Nonetheless, average body weight is still increasing to some degree in specific population groups as well as in countries that are rapidly industrialising [5], and so it is worth exploring the factors that may be contributing to this trend.

Whilst it may seem self-evident that what people eat and how much they move are voluntary, conscious (and therefore manipulable) decisions, it is becoming clear that the balance between energy intake and energy output is largely controlled by a powerful unconscious biological system [6, 7]. This biological system regulates body mass by regulating the unconscious desire to eat and to move. It is possible for an individual to wilfully manipulate this biological system to a certain degree, just as you can hold your breath for a short time, but ultimately the biological system wins out and ensures that the body returns to homeostasis through unconsciously increasing food intake and reducing movement. There are numerous mechanisms used by the body to makes these subtle changes. For example, increases in food intake result in part from increases in the production of the hormone that signals hunger (ghrelin) and decreases in the production of the hormone that signals fullness (leptin) [6, 7].

The precise ways that the components in the biological system work together in any individual are strongly genetic, and therefore associations between dietary behaviours and adiposity are strongly attenuated by genetic factors [8]. Exploration of the pathways between genetic factors, behaviors and adiposity has revealed multiple mechanisms at play. For example, the fat mass and obesity (FTO) gene, located on chromosome 16, has been consistently associated with adiposity. Recent studies have confirmed that the presence of the FTO gene is strongly associated with appetite and satiety [9], and with the number of eating episodes per day, after controlling for body weight [10]. The presence of other genes has been shown to be associated with more servings of dairy products, and different genes seem to either increase or decrease intake of proteins [10].

Genetics, environment and chance all contribute to the variation in body weight between individuals in any given population. The relative contribution of genetics to the variability in body weight in a population is referred to as heritability. Research on monozygotic (identical) twins, non-identical twins and siblings provides strong evidence for the heritability of body weight [6, 11, 12]. These studies show that between 70 and 80% of the variability in body weight can be attributed to genetic variation within the population that the twins are from. Body weight is therefore classified as 70 – 80% heritable. Heritability does not refer to the contribution of genetics to the weight of an individual person, or the relative chance of being fat if one’s parents are fat. Heritability is high when genes contribute proportionately more to the variation of body weight within the population than the environment. The heritability of body weight is second only to height, and higher than heart disease, diabetes and cancer, all of which are considered to have high levels of heritability.

Given the high heritability of body weight, there has been extensive research looking for the genes that contribute to body weight. Genetic contribution can arise from either specific locations of genetic sequences within a gene that make an individual more susceptible to higher body weight (referred to in the literature as ‘obesity susceptible loci’) or variant forms of whole genes associated with increased susceptibility (referred to as ‘obesity risk alleles’). In 2010, researchers examined the genetic makeup of almost 250,000 individuals and confirmed previous findings of 14 obesity susceptible loci associated with higher body weight. They also identified 18 new loci associated with higher body weight [13]. A 2012 meta-analysis of 14 studies of genes related to ‘common childhood obesity’ found strong evidence for 2 previously unknown obesity susceptible loci associated with children’s body weight, and some evidence for a further 2 loci [14]. Not all adiposity genes are the same; there appears to be different genetic influences on BMI and waist circumference, with only a 60% overlap in genes associated with both [12]. Not surprisingly, the influence of genetics extends beyond susceptibility to higher body weight and fat accumulation to responses to attempted weight loss. The presence of some obesity risk alleles associated with ‘early onset obesity’ in children is strongly associated with reduced weight loss in children and adolescents from behavioral weight loss interventions [15]. The role of genes and genetic loci in influencing energy regulating behaviors, heritability and weight regulation is now well established. Research in genetic mutations has also demonstrated the role of genetic changes in increased adiposity [11, 13, 16-20].

Genes however, only tell part of the story. The Foresight Report in 2007 produced an extremely complex model with 108 factors contributing to increased body weight [21]. Despite the large number of identified factors, the map only included factors related to energy intake and expenditure. There are many other factors that have been found to contribute to increased body weight for individuals, including physiological factors related to the gut, such as deficiency in Toll-like receptor 5, an immune system protein present in the gut [22], metabolic endotoxemia caused by bacterial lipopolysaccharide from Gram-negative intestinal microbiota, which leads to low grade chronic inflammation [23], the composition of microbiota in the gut [22, 24-32], and infection with helicobacter pylori [31-33]. Other types of infection have also been identified as contributing to increased body weight, including chlamydia pneumonia [33] and human adenovirus 36 [34-37].

Sleep duration and quality has been demonstrated in numerous studies to impact on body weight [38-40]. A recent review of the literature examined experimental, cross-sectional (single point in time) and prospective studies [41]. Experimental studies included in the review showed that short-term sleep restriction leads to impaired glucose metabolism, dysregulation of appetite and increased blood pressure. The cross-sectional studies reviewed demonstrated associations between sleeping less than 6 hours per night and increased body mass index, diabetes, and hypertension, but of course these types of studies cannot prove causality. Prospective studies have demonstrated a significant increase in risk of weight gain, and development of diabetes and hypertension in association with chronic inadequate sleep. Interestingly, too much sleep may also be problematic as some studies have shown an association between sleeping longer than 8 hours a night and incidence of cardiometabolic disease [41].

Different types of stress have been shown to impact on body weight, including life stress [42, 43] and cumulative work stress or job strain [44]. Brunner et al. investigated the effect that stress at work had on the development of central adiposity over a 19 year period in over 10,000 participants in the Whitehall study [44]. In addition to having a large number of participants, the Whitehall study is extremely useful because the researchers controlled for socio-economic status, eating behaviors and physical inactivity. They were therefore able to look at the effect of job stress on body weight, independent of these factors. They found that employees experiencing chronic work stress (which they defined as 3 or more episodes of stress) had a 50% increased risk of developing central adiposity compared with those without chronic work stress.

A significant body of work in recent years has demonstrated the effect on body weight of exposure to endocrine disrupting chemicals. Specific chemicals found to be associated with increases in body weight include bisphenol A (BPA) [45-48], diethylstilbestrol, tributyltin [45], perfluorooctanoate [49], dichlorodiphenyldichloroethylene (DDE), polychlorinated biphenyl, polychlorinated dibenzodioxins and polychlorinated dibenzofurans [50]. Exposure to these chemicals is widespread as they are found in products such as paints, pesticides and plastics, including food and beverage containers. Some of these studies suggest that exposure to endocrine-disrupting chemicals in-utero may cause permanent physiological damage to the fetus, reducing the capacity to regulate body weight throughout life and therefore predisposing to later weight gain [47, 50].

Other in-utero exposures have been associated with weight gain, including exposure to famine in-utero through true famine or maternal dieting [51], or over nutrition in-utero [52]. Parental factors that may contribute to increased body weight include maternal smoking [53] and child feeding practices, particularly pressure to eat and concern for child’s weight [54].

Paradoxically, one of the strongest predictors of weight gain is weight loss dieting. This is the case irrespective of actual body weight – in other words it is the case for both ‘normal weight’ people and people whose body weights are above ‘normal’. The evidence shows very clearly that the body weight that dieters are trying to reduce or avoid gaining is increased by the very behaviors used to do so. In other words, dieting is actually counterproductive to weight loss [55-59]. A study on the determinants of weight gain amongst first year university students examined a range of dieting behaviors and practices [58]. After controlling for BMI, dieting for weight loss strongly predicted weight gain over the course of the first year at university. Participants who reported currently dieting to lose weight gained twice as much weight (5.0 kg) as former dieters (2.5 kg) and three times as much weight as never dieters (1.6 kg).

One of the biggest studies to demonstrate this effect in adolescents was a prospective study of over 16,000 adolescents aged between 9 and 14 years [60]. The Growing Up Today Study (GUTS) assessed dieting behavior to control weight, binge eating, dietary intake and Body Mass Index (BMI) over a 3 year period. Over 9000 participants remained in the study for the entire period. Participants were classified as ‘frequent dieters’ (dieting 2 to 7 days a week), ‘infrequent dieters’ (dieting less than once a month to once a week) or ‘nondieters’. At the 3 year follow up period, both male and female adolescents that were frequent or infrequent dieters had gained significantly more weight than nondieters. The study controlled for potential confounding factors of BMI, age, physical development, physical activity, inactivity, caloric intake and height change over the period. Therefore the weight gain experienced by the adolescents in this study could reasonably be ascribed to the practice of dieting behaviors.

The longest running study that demonstrates this phenomenon is Project EAT (Eating and Activity in Teens and Young Adults), which involves a diverse population-based sample of middle and high school students [61]. Over 3 waves of data collection spanning 10 years, this study has demonstrated that the strongest predictors of weight gain in participants were dieting and unhealthy weight control behaviors. The analysis controlled for socioeconomic status and initial BMI, and the associations were found in participants from right across the weight spectrum. The behaviors associated with the largest increases in BMI over the 10 year period were skipping meals, eating very little, using food substitutes and taking diet pills.

In Part 1 of this article I have addressed some of the less well known contributors to increased body weight, including the strong role played by genetics, proteins and bacteria in the gut, and infections with bacteria and adenovirus. I have also discussed factors such as inadequate sleep duration and quality, chronic work or life stress, and exposure to endocrine disrupting chemicals. Finally I discussed the studies that demonstrate the contribution of dieting and weight control behaviors to weight gain over the short, medium and long term. In part 2 of this article, I will examine a range of environmental factors and their contribution to increased body weight.

Please click here to access the numbered references.

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April 24, 2012

the HAES files: Joy At Every Size

by healthateverysizeblog

by Fall Ferguson, JD, MA

Here are some things I know about joy:

The cult classic Harold and Maude (1971) explores (in a really quirky, dark way) how joy arises from participation: “A lot of people enjoy being dead. But they are not dead really. They're just backing away from life.”

I know that joy is abundantly available and yet elusive.  It arises in the doing, in the being, in the living.  You can’t just decide to have more joy; you have to participate.

I know that you can’t hold onto joy.  The moment you try to grasp it, it’s gone, and the routine of life returns with dirty dishes, laundry, and the work-a-day world.

I know that joy is hard to define.  Sometimes it’s an overwhelming moment, a big squishy lovely rush of emotion that makes it hard to swallow.  Sometimes it’s quiet and steady, like a warm, fleecy blanket.

I know that joy does not come from material things, or money, or status, or from anything external to ourselves.  Joy comes from connection, meaning, laughter, play, and love.

I know that in a moment of arising joy, we are fully present, fully human, fully ourselves.

Joy & Health: A Matter of Science

But why write about joy in a blog devoted to promoting Health At Every Size® ideas?  In my blog post last month, I promised (threatened?) to explore the multi-dimensional nature of health.  When I contemplated where to start, I kept coming back to one of my core beliefs about health: the importance of joy.  And because we don’t talk much about “beliefs” in the HAES community, I decided to investigate the research.

My search of the medical databases for articles about joy and health revealed the existence of a large number of medical researchers with the first or last name of Joy, but few reported studies.  The emerging science of psychoneuroimmunology (PNI) is making headway in demonstrating the power and importance of what we intuitively describe as the “mind-body connection,” but PNI studies tend to focus on negative influences upon health such as stress or depression rather than focusing on positive influences such as joy.

I found some evidence (mostly in the psychology databases) of a relationship between positive emotions and health.  One study differentiated between “joy” and “interest” in older adults.  While interest (defined as engagement or curiosity) was not associated with any effect upon health, joy was positively correlated with both lower morbidity and lower mortality.  Joy is also associated with many aspects of well-being, including feelings of vigor, strength, confidence, and competency (p. 53).

A Sense of Coherence

Experiencing joy also facilitates the lasting development of physical, intellectual, and social skills, according to an article in the Review of General Psychology: “Importantly, these new resources are durable and can be drawn on later, long after the instigating experience of joy has subsided” (p. 305).  And it turns out, these skills are essential to good health.  Israeli sociologist Aaron Antonovsky developed a theory of “salutogenesis” (origins of health) based on his work with Holocaust survivors.  He found that individuals with a strong “sense of coherence” fostered by what he called “generalized resistance resources” (GRRs) enjoyed better health.  High levels of GRRs, namely physical, intellectual, and emotional skills that facilitate coping and a positive outlook, are consistent with higher levels of health and longevity.  How great is it that we can develop these skills by opening ourselves to joy?

One qualitative study, titled “Joy Without Demands,” looked at the use of clowns with children in hospitals.  Putting aside my personal issues with clowns (long story), the article highlighted for me the way in which the experience of joy takes us out of our conditioned existence and into the present moment:

This joy without demands does not put the child under any obligation.  There is only the “here-and-now,” which promotes the feeling of freedom from demands and counter-demands.  The hospital clowns require nothing in return—they are simply there and provide what the child needs.  The question is whether this helps the child “just be” who he/she is deep down—a child free from disease and suffering.  When no demands are made on the child to be good, cooperate, be brave, or look happy, “a safe area” for recovery is created.

This “safe area” of joy transcends our cultural experiences of being judged and self-judgment, of striving to live up to expectations, and our experiences of stigma, bias, and low self-esteem.  The joy brought by the clowns offered the children a place where the “otherness” of illness and disease was irrelevant.  The article also noted how joy equalized the otherness of their bodies: “In the relaxed state of joy, the hospital clowns acknowledge and affirm the children as well as the staff: ‘You are seen and accepted just the way you are, your entire body too!’’’  For those of us whose bodies are culturally constructed as transgressive, the idea that joy offers a path to body acceptance is inspiring.

More Than a Means to Lifestyle Change

Surgeon General Regina Benjamin recorded a New Year’s message in early January 2012 exhorting us to “Put the Joy Back Into Health.”  [Caution: this video does contain one regrettable reference to “wanting to fit into a smaller pair of jeans.”]  This short video contains a positive public health message, no doubt.  Nevertheless, Dr. Benjamin’s exhortation to “never underestimate the power of joy in health” is couched in terms of making lifestyle changes.  To me, this leaves something out of the equation.

Similarly, Dean Ornish talks about using joy as a way to motivate people to engage in sustainable lifestyle changes: “Joy and love are powerful, sustainable motivators, but fear and deprivation are not.”  I don’t disagree with this statement, but I believe that the importance of joy goes beyond motivating us to eat well or exercise.  These instrumental arguments obscure the true importance of joy.

Joy & Health: A Matter of Faith

This may be heresy in a community that advocates for an evidence-based approach to health, but here goes: maybe what is really important about the connection between joy and health goes beyond what we can prove with medical and psychological studies and beyond the instrumental notion that joy motivates us to eat our veggies or go for a walk.

Einstein is credited with saying “everything that counts cannot necessarily be counted.”  There is a dimension of health that transcends what can be studied or measured.  Joy speaks to that dimension.

When it comes down to it, I am advocating for joy as a matter of both science and faith.  There is science to back up claims that joy is important for health and well-being.  And the truth is, even if there were no science to back it up, I would still be a huge fan of joy.

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April 17, 2012

The HAES Files: A less traveled road

by healthateverysizeblog

by Deb Lemire, President of the Association for Size Diversity and Health

Those of us who incorporate the Health At Every Size® approach in our work and personal life continually run up against the over-culture that hates larger bodies, dictates weight loss as the path to health, declares all fat bodies are automatically sick bodies, and holds that if you don’t agree then you don’t care about yourself, the children, the economy or global warming.  It’s as though everyone, except HAESSM practitioners, are haters and part of a larger conspiracy to eliminate the fat body.

But when you sit down at the table with people working on task forces or in clinics, schools, and doctors’ offices; and when you talk face to face, you find that your goals are very much the same.  Everyone truly wants to be a part of a community that supports health for people of all sizes.  It is only when we get down the road a bit do we find ourselves facing the “two roads diverged in a yellow wood.”

I recently had lunch with a colleague of mine.  Both of us work in an elementary after school program focusing on health and wellness.  While she could appreciate my HAES point of view, and knew I cared about the kids we worked with as much as she did, still she could not get past her fear for the children that she believed to be at risk for disease because of their high weights.  She felt very strongly that we would be irresponsible if we did not teach them how to lose weight. I imagine this is a familiar discussion for many of us, and there are many ways to respond.  I could remind her that we actually don’t know how to teach anyone to lose weight permanently, or that the odds of a child developing an eating disorder are far greater than the odds of that child developing diabetes.  I could point out that children of all sizes eat the same lunch in the cafeteria and play on the same playground.  I could share information on how socio-economic status, genetics, environment and stigma impact the physiological development of a body.  In fact, in past discussions I have brought all of this to the table.  It seemed to me that she simply wasn’t hearing what I was saying.  But I realized that it was I who wasn’t listening.  It isn’t about the statistics or disease.  It is about fear.  Fear that if we do not comply with the over-culture we will harm our children.  And speaking as a parent, there is no fear greater.

So maybe we should take the opportunity to reframe their fears and then re-imagine those outcomes defined by fear as outcomes defined by hope.

Road Not Taken

We shouldn’t fear that children won’t eat the right thing, but rather that they will go hungry and have no access to healthy food; so we are motivated by hope to provide better sustenance for our children.

We shouldn’t fear that our children will sit in front of video games all day, but rather that they will not have safe places to play outside; so we are empowered by hope to curb violence in our communities.

We shouldn’t fear that our children will be bullied because their bodies are different, but rather that they will never realize their true awesomeness; so we are fueled by hope to create a community of belonging and love.

These fears are not unfamiliar to those of us who embrace the HAES model.  We’ve all traveled the fear road. But unlike the traveler in Robert Frost’s poem, we did come back to where the two roads diverged in that wood, and this time we “took the one less traveled by”: Hope. And that can make all the difference.

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April 10, 2012

the HAES files: Food Phobic Nation—A Brief History

by healthateverysizeblog

by Jon Robison, PhD

“Good nutrition is getting a bad name — one that smacks of rigidity, guilt-making and extremism… Worse still, some eight out of ten (Americans) think foods are inherently good or bad… every single bite they take represents an all-or-nothing choice either for or against good health.”

Unfortunately, this two-decade-old pronouncement from the Tufts University Diet and Nutrition Letter still rings true today. Americans live in a constant state of anxiety and confusion when it comes to food. We have been warned of the need for constant vigilance to protect ourselves from the dangers lurking in a wide variety of foods. As a famous diet doctor cautioned:

“You must treat food as if it were a drug. You must eat food in a controlled fashion and in the proper proportions – as if it were an intravenous drip.”

For many, if not most adults, a longing glance at a desired food is sure to elicit the following inner dialogue:

“I wonder how many calories, fat grams, carbohydrates, etc. are in that food…I don’t know if I should eat it…Will it give me heart disease, diabetes, cancer?…Will it make me fat?”

If the desire to eat ends up winning out over the fear, which it usually does, the anxiety, now intensified by the guilt of not having resisted, returns:

“I’ve really blown it now…how many miles am I going to have to walk, run, bike, etc. to get rid of those calories…”

And in response to the possible eventuality of acquiring some affliction in the future:

“Now I’ve gone and given myself a heart attack, stroke or cancer. That never would have happened if I hadn’t eaten this or that food.”

Over the years the ongoing barrage of proclamations from the government and health organizations about the “badness” (unhealthiness) of various foods has managed to wrench from many of us the natural pleasures of eating while turning food selection into an intellectual activity, replete with mathematical calculations, “shoulds” and “shouldn’ts” and dire warnings of dreaded consequences.

It started in the 1970s and 80s with the fear of fat – lipo-phobia. According to the experts, all fat was bad and we should eat as little of it as possible. But wait! Scientists soon discovered that only saturated fat was bad for the heart, while other fats were not. Then they discovered that only some saturated fats were bad while others were not. Then they said that polyunsaturated fats were good. Then they told us that, although polyunsaturated fat helped with the bad cholesterol it also lowered the good cholesterol, so what we really should be eating was monounsaturated fat.  Then research suggested that a low fat diet might actually be unhealthful for a significant portion of the population.

Confusing as all this was, most experts agreed about what should make up the bulk of our diet!  – Lots and lots of carbohydrates! Hold the burger, eat the pasta! Then came Gary Taube’s fateful 1991 New York Times editorial entitled: What if it has all been a Big Fat Lie?  Seemingly overnight we traded in our nearly quarter-century-long lipo-phobia for a new fear – the fear of carbohydrates – carbo-phobia – Hold the pasta, eat the burger (without the bun of course!).

To make matters worse, special interest groups have promulgated a host of other food phobias that continue to haunt people as they try to decipher what might be left that is still safe to eat. With little or at best contradictory scientific evidence for the claims, we have been told that meat is bad for the kidneys, that milk should not be consumed past childhood, that the cholesterol in eggs causes heart attacks, that sugar makes children hyperactive, that High Fructose Corn Syrup is a major cause of “the obesity epidemic” and so on.

Is it any wonder that in a 2001 survey in the Journal of The American Dietetic Association, 43% of those polled said they were tired of hearing about what foods they should or should not eat and 70% said that the government should get out of the business of telling people what to eat? Perhaps not surprisingly, the media headlines recently heralded a study in the Journal of Nutrition that concluded “Nearly everyone fails to meet Dietary Guidelines.”

We are in desperate need of a serious serving of common sense when it comes to eating. With the possible exception of the recent “pink slime” (ammonia treated by-products in ground beef) nightmare, viewing foods as weapons of mass destruction is scientifically unsound and psychologically destabilizing. In fact, our burgeoning fear of foods has actually spawned a new eating disorder – orthorexia nervosa – the obsession with eating only “healthy” food.

With all of the admonitions to avoid this food, eat less of that food, and be sure not to get more than this percentage of calories from this food, maybe it is time to get back to basics. Wasn’t it grandma who said many years ago – drink your milk, eat your fruits and vegetables and go out and play? Maybe we need to reevaluate our alimentary recommendations. In this regard, perhaps we could follow the lead of our mother country across the sea, whose enlightened number one dietary guideline is – Enjoy Your Food!

Sadly, the committee responsible for the 1995 Dietary Guidelines for Americans came one vote short of including “Enjoy a Variety of Foods” in their recommendations for fear that such wording “would unleash unlimited license” for people to eat “whatever.” The rest, as they say, is history.

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April 3, 2012

the HAES files: Taking the Health At Every Size® Model to School–A Lesson in Patience* and Perseverance

by healthateverysizeblog

by Dana Schuster, MS

(*Not my natural inclination)

I should start off by admitting that I have been described as suffering from “Pollyanna syndrome” along with a type-A personality driven by high expectations for both others and myself. According to my mother, I was born with a fierce determination and persistence, not to mention the tendency to quickly point out the “good” in any situation. You know, like when at age 2, you drop a full glass of milk all over the floor and immediately announce “aren’t you glad the glass didn’t break!” But as many of you know from personal experience, it is not a walk in the park to get even well-meaning adults off the battlefield and onto the peaceful path of weight neutrality that is the HAESSM model.

Over the past seven years I have been involved with two school district Wellness Committees and a countywide task force on improving the nutrition and physical activity habits of youth. While most members of these groups focus on implementing strategies aimed at combating the “childhood obesity epidemic,” I am busy trying to embed a Health At Every Size® approach as broadly as possible into their thinking, their materials, and the services being developed for use in both school and community settings. During this time I have come to accept the three following baseline concepts:

  • One must develop “tactical spinning” skills.
  • Victory will be measured in child-sized steps.
  • Pit-bull tenacity, with teeth bearing only on select occasions, is a necessity.

Okay, so the pit-bull part comes pretty naturally to me, although minimizing the “showing of teeth” continues to be a challenge. My passion often gets the best of me, and while it serves well in some situations, it has also pushed some of my more conflict-avoidant colleagues to step back and hope that our paths didn’t cross too often. Despite this occasional outcome, employing the three concepts mentioned above has facilitated the infusion of the HAESSM perspective into the work being done.

For example, the original name of the county group I serve on was the Prevention of Childhood Obesity Task Force.  At the first meeting, and at every opportunity thereafter, I pointed out that framing our work in terms of obesity was a poor choice as it placed negative judgment on children whose bodies were of a certain size. I emphasized that the obesity focus caused stigmatization and might increase bullying, as well as ignoring the very real and significant health risks of eating disorders such as anorexia. Finally, I suggested that we wanted health supporting nutrition and regular fun physical activity for ALL children. It took two years of reminding people of these concerns, both individually and at every meeting, workshop, and committee I attended, before the name was changed to the Get Healthy San Mateo County Task Force.  This victory clearly employed both the concepts of tactical spinning and tenacity, and although it might have at least in part resulted because people were just totally tired of hearing me go on about this, I really don’t care. When I see the new name on websites, brochures, and announcements, and hear it verbalized in presentations, it is evident that this change is influencing how people are framing the programs under the task force umbrella.

Another example of how tactical spinning can be effective – if you are willing to measure success in child-size steps – occurred when an evaluation sub-committee I serve on was selecting the data sources for a report. Statistics noting the number of children with a BMI that placed them in the “at risk” or “overweight” categories were of course chosen, and it was clear that my colleagues were not going to abandon what they considered an important source of information. However, when I pointed out that if they insisted on using BMI measures and were really focused on health, then we had a responsibility to monitor the statistics for the low-end BMI numbers as well, since these suggested youth at risk for eating disorders.  While this did not get rid of the BMI as a marker, which would be the HAESSM goal, it does shift thinking to a more inclusive perspective, and has helped in a small way to mitigate the constant focus on obesity.

As I staff information tables at high school health fairs, help lead activities with elementary children at “Make Time for Fitness” events, and serve on committees that are crafting “interventions” to improve the nutrition and physical activity habits in schools, I have found the following can have a powerful impact:

  • Have a YAY! Scale (Marilyn Wann’s brilliant creation) with you and repeat whatever it says to the person on it with conviction and a smile.
  • Hand out “Power Thoughts for Teens” cards to middle and high school students.
  • Encourage youth to take care of their health because they are fabulous and deserving and not because there is anything wrong with them or the size/shape of their bodies.
  • Remind colleagues that eating disorders can be deadly and are inadvertently encouraged when getting rid of obesity is the focus.
  • Emphasize being inclusive and the importance of making sure thinner kids also have the information and opportunity to choose nutritious foods and engage in fun physical activity.
  • Gently educate others that giving the direct or indirect message that a certain size of body is unacceptable creates stigma and supports bullying.
  • Volunteer to take the notes, help write the policy draft, assemble the materials for the health-fair table, select the physical activity to be taught, or serve on that extra committee whenever possible, and you will find you have an opportunity to shape or frame things right from the beginning.

Some days my energy lags, my sanity points dip down into the dangerously low zone, or one more horrible obesity intervention rears its ugly head, and I wonder if I am engaged in a losing effort. And then I remember the look on the fat girl’s face when I cheer on her hula hoop efforts, or the words of the high school boy who steps on the YAY!Scale and announces he needs to do this every morning so he can carry the message with him all day. Then I know in some small way, the HAESSM message is seeping in to wreak powerful havoc in our weight-centered culture.

Pollydana the pit bull…I like the sound of that.

healthateverysizeblog note: Here are some resources that may be useful for anyone seeking to reframe “childhood obesity” issues as a concern for health for all children:

AED Guidelines for Childhood Obesity Prevention Programs

“A call to action: Reject labeling children & adolescents as obese.”

“Helping Without Harming – Kids, Eating, Weight and Health”

NAAFA Child Advocacy Toolkit

“What should we do about children and weight?”

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March 27, 2012

the HAES files: How to Photoshop a Research Study

by healthateverysizeblog

[as demonstrated by Rock et al. (2010) on weight loss results of the Jenny Craig® program]

by Deb Burgard, PhD

1. Publish in a peer-reviewed, respectable journal like JAMA. The average person has no idea they are willing to publish research sponsored by industry, so the fact that Jenny Craig paid for this will stay buried in the fine print on page 1810.

2. You’re the researcher, so you get to choose who can be in the study. Forget the bother of a representative sample.  Make sure you eliminate at least 20% of your interested participants right off the bat, even though you don’t do that with your customers.  Who’s going to notice that you don’t have even a representative sample of your customers, let alone a representative sample of the “obese and overweight women” of your title?

3. Don’t bother to test your actual program−too many people would drop out.  Instead, pay your participants for showing up to clinic visits, and give away your diet food.  Readers won’t realize that you are not really testing your real-world program, which costs $100/week.  Don’t report on (or maybe even bother to track) the percentage of people who actually chose to eat the (free!) food−just track whether people showed up at the center or talked on the phone.  Don’t report on the percentage of people who would not eat Jenny Craig food even when it is given away.

4. Identify the study participants to your staff, for no discernible reason.  Could it be so they can be sure to work extra hard to get the desired results?  But report on how you told them to treat everyone the same, as if that is an accepted research procedure.

5. Say your study tests maintenance of weight loss, but don’t ever stop your intervention.  Who’s going to notice the difference between a two-year study of continuous dieting vs. a study that actually follows up, i.e., shows what happens two years after the intervention is over?

6. Report in BMI, kg, and means so that readers won’t do the math and translate into what is familiar to them.  Who’s going to go back and look at the average baseline weight of 92 kg and multiply by 2.2 then figure out what 5% of that would be (about 10 pounds) to understand that this statement, “By study end, more than half in either intervention group (62% [n=103] of center-based participants and 56% [n=91] of telephone-based participants) had a weight loss of at least 5% …” means that 59% of the people who showed up at clinic visits were at least 10 pounds lighter at two years out, going from an average of 203 pounds to 193 pounds?  Who’s going to subtract to figure out that even when they were getting paid and the food was given away for free, 41% of the participants could not maintain even a 10 pound average loss?

And really, who would actually divide to notice that it took an average of $6958 over two years to return an average weight loss of 15 pounds, or $463.87 per pound all while losing your sanity points being on a continuous diet for two years?

7. Count on no one noticing that even when you are paying people over $3000/year in food products and counseling rather than asking them to pay over $3000/year in the real world, the average weight trajectory is on the way back up after month 12.

8. Claim in the results section that the intervention groups reported better quality of life and reduced depression at 12 months; maybe people won’t notice that sure enough, at 24 months there were no significant changes from baseline in physical fitness or psychosocial measures.

9. Make sure to end your study at the point when you stop paying people, but describe the study in the abstract as “conducted over 2 years with follow-up between November 2007 and April 2010.”  Who reads the actual article anyway?

10. Make sure you publish your study side-by-side with an independently-conducted study but make sure that one stops at the 12-month point in the process where people tend to have maximum weight loss and benefits, even though studies consistently show this reverses over the next year.  That way your sponsoring company can send out its press release mashing everything together and imply all kinds of results no one found in either study, like you had a “two-year independent, multi-site clinical trial” (OK, the independent trial was a only a year and only one site) and “those who took part in the Jenny Craig program adopted healthier eating habits and meaningful health benefits for overall improved quality of life” (OK, the quality of life changes were not significant at 24 months) and “those following the program reduced risk factors that can lead to chronic disease including depression, diabetes, cancer and even stroke” (OK, there were no significant changes at 24 months in total cholesterol, LDL cholesterol, HDL cholesterol, or triglycerides, or step test fitness measures, or any psychosocial measures including depression).

Hey, if Vogue can get away with it, why not JAMA?

Posted in Deb Burgard | 17 Comments »

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